Obstetrician-Gynecologists' Opinions on Elective Bilateral Oophorectomy at the Time of Hysterectomy in the United States

A Nationwide Survey

Oz Harmanli, MD; Julia Shinnick, BS; Keisha Jones, MD, MSc; Peter St Marie, BS

Disclosures

Menopause. 2014;21(4):355-360. 

In This Article

Abstract and Introduction

Abstract

Objective. This study aims to assess obstetrician-gynecologists’ opinions on elective bilateral oophorectomy (BO) at the time of hysterectomy in the United States and to describe factors that influence their views.

Methods. In April 2012, an anonymous survey was mailed twice to practicing obstetrician-gynecologists, randomly selected from a list produced by the American Medical Association, in an effort to assess their opinions regarding elective BO at the time of hysterectomy. The effects of gynecologists’ various characteristics on their opinions were also evaluated.

Results. Of 1,002 mailed surveys, 443 (44%) were returned completed. Of the respondents, 59% were male and 79% were white. The largest age group was 51 to 55 years (20%), and the mean time since completion of residency was 23 years. In women with an average risk of ovarian cancer, the proportions of physicians who favored elective BO were as follows: women younger than 51 years, 32%; women aged 51 to 65 years, 62%; women older than 65 years, 6%. These recommendations were not influenced by the physicians’ age, sex, training, or geographic region. If a hysterectomy candidate was younger than 51 years and had a personal history of breast or ovarian cancer and a family history of ovarian cancer, these proportions were increased to 77% and 64%, respectively. Other factors that influenced the respondents’ recommendations were the women’s personal history of cardiovascular disease (21%), osteoporosis (23%), and sexual dysfunction (23%).

Conclusions. One third of obstetrician-gynecologists continue to recommend elective BO for hysterectomy candidates younger than 51 years. The majority recommend elective BO for women aged 51 to 65 years. Their demographic characteristics do not influence their opinions.

Introduction

Elective bilateral oophorectomy (BO) during hysterectomy is the most effective way to prevent ovarian cancer in women undergoing this procedure for benign conditions.[1] This was a common practice because it was assumed that loss of ovarian hormonal production could be easily rectified with administration of exogenous estrogen therapy. This practice pattern was reflected in the increased proportion of hysterectomies performed with BO from 1979 to 2004.[2] However, this trend later changed, and a decline in elective BO rates was observed between 2002 and 2006.[3,4] Surprising results from the Women’s Health Initiative (WHI) study that questioned the perceived benefits of hormone therapy probably contributed to this trend.[5] The changing sentiment was later energized by a decision analysis published by Parker et al[6] in 2005. Their report suggested that ovaries should not be removed prophylactically until 65 years of age as mortality from coronary artery disease and hip fracture might increase after prophylactic oophorectomy. This publication received significant skepticism as it was a decision analysis‐not a new study on women but a mathematical calculation of potential outcomes from previously published data. Yet it invigorated a heated debate and stimulated additional research.[7,8] Consequently, the American College of Obstetricians and Gynecologists (ACOG)[1] revised its recommendations on this issue. Although ACOG recommended in 1999[9] that age no longer be the only factor considered in the decision to perform elective oophorectomy, this procedure was formally discouraged in premenopausal women in an ACOG practice bulletin in 2008.[1] However, unlike Parker et al, who advocated ovarian conservation until 65 years of age, ACOG[1] suggested using menopause as the critical threshold for considering elective ovarian removal at the time of hysterectomy.

Whether practitioners draw the line at 51 or 65 years of age may have significant clinical implications when they recommend elective BO to a hysterectomy candidate. Data on American obstetrician-gynecologists’ current views about ovarian conservation at the time of hysterectomy are limited. The manner in which a physician provides counseling regarding elective BO may differ according to a physician’s age, training, experiences, and personal beliefs. Likewise, a physician’s views will vary depending on a woman’s risk of developing breast or ovarian cancer, heart disease, osteoporotic hip fracture, and potential need for exogenous estrogen. The objective of this study is to assess obstetrician-gynecologists’ opinion on elective BO at the time of hysterectomy in the United States and to describe factors that influence their decision-making.

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